SummaryFailed spinal anaesthesia for left total hip arthroplasty was followed postoperatively by dense motor paralysis and sensory deficit in the right leg. The patient had received a dose of subcutaneous heparin 1 h before the spinal anaesthetic was attempted. She died of pulmonary embolism on the ninth postoperative day. At autopsy extensive haematomyelia was found in relation to the needle track. Case reportAn overweight woman of 66 years (height 163 cm weight 87 kg) presented for a left Charnley total hip replacement. She had a history of deep vein thrombosis some 10 years previously, apart from which and notwithstanding her weight, she had remained in good general health. Her only medication was fenbufen for arthritis, which she had not taken for 1 week prior to the operation and co-codamol as required for pain. The patient was frankly advised of the danger of hip surgery but was keen to proceed because her arthritis was severely disabling and her pain constant. She had been waiting for surgery for some months and had been able to lose 8 kg in weight.Pre-operative laboratory investigations showed a haemoglobin of 12.9 g.dl ÿ 1 and platelets of 170 000 × 10 9 .l ÿ 1 . The patient's clotting function was not investigated.Despite the practical difficulties caused by her weight, regional analgesia was chosen. Premedication was with midazolam 5 mg intramuscularly and low-dose heparin was prescribed (5000 i.u. calcium heparin subcutaneously twice daily) the first dose being given 1 h pre-operatively.Spinal anaesthesia was attempted in the left lateral position with a 26G needle. It was extremely difficult to palpate the bony landmarks of the back but the subarachnoid space was located at the first attempt in what was believed to be the L 3-4 interspace and free flow of cerebrospinal fluid was observed. On injection of the local anaesthetic the patient complained of intense pain, described as sharp and stabbing in nature, down the left leg. The subarachnoid injection was abandoned and the needle withdrawn. A total of 0.3 ml of heavy bupivacaine 0.5% in 12% dextrose had been injected. The situation was discussed with the patient who was now pain free and it was decided to proceed with general anaesthesia. This was induced with thiopentone 250 mg and controlled ventilation with nitrous oxide, oxygen 30% and isoflurane 0.5% was facilitated with vecuronium. A total of 12 mg of morphine was administered during surgery. The operation was uneventful and the systolic blood pressure remained in the range 110-140 mmHg throughout. The duration of surgery was 90 min.The patient complained of moderate pain at the operative site and was given a further 5 mg of morphine intravenously in the recovery unit. Her immediate postoperative progress was otherwise unremarkable. The following morning when the patient awoke she complained that her right leg was numb and weak. Neurological examination confirmed this and neurological and neurosurgical opinions were sought. ᮊ 1997 Blackwell Science LtdOn physical examination a right-sided u...
The impact of blood culture systems on the detection of coagulase-negative staphylococcal bloodstream infections in critically ill patients prior to and following the introduction of the Bactec 9240 blood culture system (Becton Dickinson Diagnostic Instrument Systems, USA), which replaced the Bactec NR 730 (Becton Dickinson Diagnostic Instrument Systems), was investigated over a 3-year period. Following the introduction of the new culture system, the incidence of bloodstream infections doubled (P<0.001). Patient demographics, severity of illness, and mortality remained unchanged, while the annual standardized mortality ratio decreased significantly. These data suggest that blood culture systems may have a major impact on the perceived incidence of coagulase-negative staphylococcal bloodstream infections in this population.
Introduction Community-acquired pneumonia remains a common condition worldwide. It is associated with significant morbidity and mortality. The aim of this study was to evaluate conditions that could predict a poor outcome. Design Retrospective analyse of 69 patients admitted to the ICU from 1996 to 2003. Demographic data included age, sex and medical history. Etiologic agents, multiorgan dysfunction, nosocomial infections, SAPS II and PORT scores were recorded for each patient. For statistical analysis we used a t test, chi-square test and Mann-Whitney U test on SPSS ® . A value of P less than 0.05 was considered significant. Results Forty-seven patients were male and 22 patients were female. Mean age was 52 years. Sixty-seven percent had serious pre-morbid conditions including pulmonary disease (34.8%), cardiac problems (36.2%), diabetes (13%) and chronic liver disease (5.8%); 40.6% were smokers, drug abusers or alcohol dependents. Sixtyeight patients required invasive mechanical ventilation. The average length of ventilation was 13.5 days, median 8 days. The mean SAPS II score was 40.14 and the mean PORT score was 141. The mortality rate was 27.5% (SAPS II estimated mortality, 35%). Complications reported were ARDS (40.6%), septic shock (34.8%), acute renal failure (2.9%), cardiac arrest (8.7%) and nosocomial infeccions (46.4%). Mortality rates were higher for previous hepatic (75%) and metabolic (33%) diseases. We found a close association between crude mortality and SAPS II score (P = 0.003) and development of complications (P = 0.0028). Respiratory dysfunction (P = 0.006) and septic shock (P = 0.022) were most significantly related to mortality. No significant differences were founded regarding age, comorbidities, PORT score, etiologic agents, nosocomial infections and length of invasive mechanical ventilation. Conclusions Previous hepatic chronic disease was strictly related to higher mortality as well as isolation of MRSA. ARDS and septic shock predicted a poor outcome. SAPS II score was the best severity indicator of mortality. P2 Closed endotracheal suction system without periodic change versus open endotracheal system
During invasive mechanical ventilation due to the dryness of medical gases is necessary to provide an adequate level of conditioning. The hot water humidifiers (HWH) heat the water, thus allowing the water vapor to heat and humidify the medical gases. In the common HWH there is a contact between the medical gases and the sterile water, thus increasing the risk of patient's colonization and infection. Recently to avoid the condensation in the inspiratory limb of the ventilator circuit, new heated ventilator circuits have been developed. In this in vitro study we evaluated the efficiency (absolute/relative humidity) of three HWH: (1) a common HWH without a heated ventilator circuit (MR 730, Fisher&Paykel, New Zeland), (2) the same HWH with a heated ventilator circuit (Mallinckrodt Dar, Italy) and (3) a new HWH (DAR HC 2000, Mallinkckrodt Dar, Italy) with a heated ventilator circuit in which the water vapor reaches the medical gases through a gorotex membrane, avoiding any direct contact between the water and gases. At a temperature of 35°C and 37°C the HWH and heated tube were evaluated.The absolute humidity (AH) and relative humidity (RH) were measured by a psychometric method. The minute ventilation, tidal volume respiratory rate and oxygen fraction were: 5.8 ± 0.1 l/min, 740 ± 258 ml, 7.5 ± 2.6 bpm and 100%, respectively. Ventilator settings were maintained constant for all the study period. The measurements were taken after 60 min of continuous use.At 35°C the output of the MR 730 with a heated tube was insufficient to provide adequate levels of conditioning, while at 37°C all the three devices were satisfactory. Airway techniques for percutaneous tracheostomy include the LMA, the Combitube, the Microlaryngeal tube and the Perforated Airway Exchanger. Routine bronchoscopy is deemed unnecessary by many, including intensivists in Cardiff. Our audit database stores patient characteristics, techniques and complications, in 700 tracheostomies.A bougie was used during 46. This technique does not use bronchoscopic control. A bougie is passed through the tracheal tube (TT) into the trachea. The TT is withdrawn until the cuff is above the vocal cords. With the cuff fully inflated, the TT is advanced (using the bougie as a guide) until the cuff impacts on the vocal cords. A gas- Critical Care March 2004 Vol 8 Suppl 1 24th International Symposium on Intensive Care and Emergency Medicineseal is maintained by gentle pressure on the TT keeping the cuff pressing on the vocal cords. During percutaneous tracheostomy the bougie remains in the trachea. When ventilation through the tracheostomy tube (cuff inflated) is confirmed, the TT and bougie are withdrawn. Throughout the procedure, if ventilation difficulties occur, the TT can be easily re-inserted using the bougie as a guide.Results Three different bougies were used: types (number used) were Eschmann (29), size 10 Portex disposable (four) and size 12 Portex disposable (13). Three patients were trauma cases: a neutral cervical position was maintained. In 33 cases the Blue ...
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